Provider Demographics
NPI:1982205332
Name:CHAMPION, MICHELLE JEAN (LAC)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JEAN
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:JEAN
Other - Last Name:BUMMINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:PO BOX 1950
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-1950
Mailing Address - Country:US
Mailing Address - Phone:707-263-8383
Mailing Address - Fax:707-263-5019
Practice Address - Street 1:925 BEVINS CT
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-9754
Practice Address - Country:US
Practice Address - Phone:707-263-8383
Practice Address - Fax:707-263-5019
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12768171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty